Vol. VIII, No. 8 ~ EINet News Briefs ~ Apr 15, 2005

Appropriate biosafety measures were immediately taken at the involved laboratory in Canada and respiratory surveillance measures initiated. Subsequent investigation by the Public Health Agency of Canada traced the source of the H2N2 virus to a panel of proficiency testing samples containing influenza A and influenza B viruses which the Canadian laboratory received from the College of American Pathologists (CAP) Feb 2005. CAP routinely sends various panels of proficiency testing samples to participating laboratories every year. Normally, currently circulating influenza A viruses (H3N2; H1N1) are used for proficiency testing. The H2N2 virus was distributed by CAP for the first time Oct 2004.

WHO, the US Department of Health and Human Services (HHS) and CDC were informed of the situation by PHAC 8 Apr 2005. The problem arose when Meridian Bioscience Inc. sent a panel of virus samples to about 3700 laboratories, some in doctors' offices, to be tested as part of routine quality-control certification conducted by the CAP. The 3700 samples were sent out beginning last fall. Neither the CAP nor Meridian was aware that the virus being shipped was the 1957 strain, said a spokesman for the college. The college asked the company to ship a type A strain of virus, and Meridian's paperwork indicated that this strain was benign. Subsequent investigation revealed that similar proficiency testing samples with H2N2 virus were sent to 3747 laboratories in 18 countries. 61 of these laboratories are located in 16 countries outside the USA and Canada. HHS has recently learnt that other proficiency testing providers have sent additional H2N2 containing samples to further laboratories in the USA.

On 8 Apr 2005, CAP asked all laboratories which participated in the proficiency testing to immediately destroy samples containing the H2N2 virus. On 12 Apr 2005, a second correspondence from CAP to these labs further requested that destruction of the H2N2 virus be confirmed and that any case of respiratory disease among laboratory workers be investigated and notified to national authorities. WHO has received the list of addresses of the involved laboratories and has provided detailed contact information to the relevant Ministries of Health and requested their collaboration.

As of 12 Apr 2005, there have been no reports of H2N2 infections in laboratory workers associated with the distribution of the H2N2 samples. The proper use of biological safety cabinets, along with the use of recommended personal protective equipment, greatly reduces the risk of laboratory-acquired influenza infections. While a few H2N2 laboratory acquired infections have been documented in the past, the likelihood of laboratory-acquired influenza infection is considered low when proper biosafety precautions are followed. The risk for the general population is also considered low. WHO recommends that biosafety procedures be reviewed for use on influenza viruses that have not circulated recently in humans and against which the majority of the population would have no protective immunity.

List of countries and areas that have received H2N2 influenza virus: Bermuda, Belgium, Brazil, Chile, France, Germany, Hong Kong, Israel, Italy, Japan, Lebanon, Mexico, The Republic of Korea, Saudi Arabia, Singapore, Taiwan, and China.

CDC also offers the latest information (http://www.cdc.gov/flu/h2n2situation.htm), with updated links to:
- CDC Health Update: Instructions for Monitoring Health of Laboratory Workers and for Destroying Influenza A (H2N2) Samples
- Q & A: Influenza A (H2N2) Panels
- CDC Health Advisory: CDC & WHO recommend that sample panels of influenza A/H2N2 be destroyed
- Press Conference Transcript: Update on Distribution of H2N2 Influenza Strain
- WHO Statement: International response to the distribution of a H2N2 influenza virus for laboratory testing: Risk considered low for laboratory workers & the public (WHO 4/12/05, Promed 4/13/05; CDC 4/15/05)

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Economy / Unofficial (Official) Cases / Unofficial (Official) Deaths
Cambodia / 3 (3) / 3 (3)
Thailand / 0 (0) / 0 (0)
Viet Nam / 41 (33) / 16 (15)
Total / 44 (36) / 19 (18)
(CIDRAP, 4/15/05 http://www.cidrap.umn.edu/cidrap/content/influenza/avianflu/case-count/avflucount.html)

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East Asia: FAO Latest information on Avian Influenza, summary report
Outbreaks of H5N1 Highly Pathogenic Avian Influenza (HPAI) in poultry were reported in Thailand, Viet Nam, Cambodia and Indonesia during Mar 2005. A new outbreak is currently being investigated in Democratic People's Republic of Korea. FAO's diagnostic laboratory and surveillance network project for East Asia is providing assistance in diagnosis. Although the number of outbreaks have decreased in Thailand and Viet Nam, the need for vigilance to find potentially new cases and their rapid isolation remain high priorities. Biosecurity in the domestic poultry production system is of utmost importance.

Viet Nam: Last known outbreak: 29 Mar - 4 Apr 2005. Total of 1300 ducks have either died or been culled in Tra Vinh Province. The confirmed human cases in Viet Nam reported by WHO have been 33 since 30 Dec 2004, of which 15 were fatal.

Thailand: Last known outbreak: 10-17 Mar 2005. Total of 50 birds have died or been culled in Ban Dan Lan Hoi district, Sukhothai Province.

Cambodia: Last known outbreak: 22-28 Mar 2005. Total of 139 chickens and ducks have been culled in Keatha Vong Leu village near Vietnamese border. A 28-year-old man who died 22 Mar 2005 and an 8-year-old girl who died 07 Apr 2005 both from Bantey Meas district, Kampot Province were confirmed to have been infected with H5N1.

Indonesia: During Jan - Mar 2005, HPAI had killed a total of 281 730 birds in Central Java, South Sulawesi and West Java Provinces. In Central Java Province, quail farms have been affected and over 77 000 poultry have either died or been culled. Inter-island chicken trade from South Sulawesi has been banned since mid Mar 2005. In West Java Province, 21 000 dead chickens were reported Jan - early Mar. HPAI had mostly affected quails in West Java. In Cirebon (declared as an epidemic area), destroyed quails were said to have been brought from Sleman (Yogyakarta). Some 200 000 doses of vaccine against H5N1 infection had been distributed to infected areas, and the government has set aside Rp 750 million (USD 79 000) and Rp 250 million [USD 26 000] backup fund to assist poultry breeders who destroyed their bird flu-infected flocks. Since 31 Mar 2005, West Java authorities have stopped all poultry traffic into the area. The poultry-check operation targeting chickens, quails and ducks was held in Losari.

Democratic People's Republic of Korea (DPRK): Outbreak of avian influenza was reported in 3 chicken farms including the Hadang Chicken Farm in Pyonyang province. The State Emergency Veterinary and Anti-Epizootic Committee has been organized and movement control, and increased surveillance in poultry farms has been implemented. A total of 219 000 poultry have been slaughtered. Increased mortalities were observed in Hadang Farm, and in 2 neighboring farms belonging to the same company. Veterinary authorities have vaccinated birds in these farms and the vicinity. A FAO expert is working with DPRK authorities in the diagnosis. Indirect evidence suggests that the strain is H7. (Promed 4/14/05; FAO http://www.fao.org/ag/againfo/home/en/home.html)

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Indonesia, Thailand and Viet Nam: FAO “Focus on the issues”
Impact figures for the avian influenza epidemic are staggering. More than 140 million birds have died or been destroyed. Combined losses to gross domestic product (GDP) are estimated at US$10 billion to US$15 billion. An FAO study estimates that in Viet Nam alone, the disease has touched 36 000 people living on the edge of poverty and 88 000 who were already poor. Ten countries are affected: Cambodia, China, Indonesia, Japan, the Lao People's Democratic Republic, the Republic of Korea, Malaysia, Pakistan, Thailand and Viet Nam. This FAO “Focus on the issues” covers three countries hit hard by the disease: Indonesia, Thailand and Viet Nam.
Relevant links:
- Debt and distress: the human impact
- Virus detective work in Indonesia
- To vaccinate or not
- Containing infection at source - signs of success
- Army of volunteers helps detect flu early
- Better disease prevention is the answer
- Bird flu: North Korea appeals for assistance
- Photo gallery: fighting bird flu
- FAO Avian Influenza Special Report
- FAO's Animal Production and Health Division
(FAO 4/11/05, http://www.fao.org/newsroom/en/focus/2005/100356/index.html)

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Viet Nam: 71 percent of ducks in southern Viet Nam infected with bird flu
Initial testing has shown that 71 percent of ducks and 21.4 percent of chickens in Viet Nam's 11 southern localities in the Mekong Delta are infected with bird flu virus strain H5. Up to 80 percent of 2000 samples taken from ducks raised in Can Tho city, which is home to 1.5 million poultry, tested positive to H5, saud local newspaper Youth 13 Apr 2005, quoting recent tests by the country's Regional Veterinary Center. The situation poses challenges to many localities, because a great number of ducks are raised freely in fields and canals in the delta, which practice can spread the disease. Moreover, many local farmers protest the forced culling, saying that their ducks are totally healthy and not yet confirmed as H5N1 infected.

On 1 Apr 2005, Viet Nam started a month-long campaign to clean up poultry farms nationwide in a move to stamp out bird flu, which has hit 35 cities and provinces nationwide since Jan 2005. 33 localities have so far detected no new affected spots in their territory for 3 weeks, meeting the country's criteria to announce an end to the disease. To minimize the risk of infection, it has intensified publicity, urging local people not to eat dishes made from raw duck blood or to slaughter sick poultry for food and to avoid coming into contact with fowl without wearing protective gear. The role of ducks as reservoir of infection in Eastern Asia has been addressed during the recent FAO/OIE consultation, which concluded that the possibility of vaccinating ducks should be explored. Experimentally, vaccines have been shown to significantly reduce AI virus replication and shedding in domestic ducks and geese and thus decrease environmental contamination and prevent contact transmission. (Promed 4/13/05)

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Viet Nam: Avian influenza WHO situation update
The Ministry of Health in Viet Nam has provided WHO with official confirmation of an additional eight human cases of H5N1 avian influenza. Two of the cases were recently detected, between 2 and 8 Apr 2005, in Hung Yen and Ha Tay Provinces, respectively. Both patients are alive. The other six cases are thought to have been detected prior to 2 Apr 2005. WHO is seeking further details from the authorities on these six cases. The Ministry of Health has reported to WHO that 41 cases from 18 cities and provinces have been detected in Viet Nam since mid-December 2004. Of these cases, 16 have died and six remain under treatment. (WHO 4/14/05)

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Viet Nam: HIV Carrier Infected with Avian Influenza Virus
A 21-year-old woman has been infected by both the HIV/AIDS virus and avian influenza virus, the first such case in Viet Nam, health officials said 14 Apr 2005. Nguyen Van Thich, head of the Centre for Preventive Medicine in Quang Ninh, said the woman used to work at a hairdressers's shop. She was hospitalised late Mar 2005 with fever and coughing. "She is still very weak," he said, adding that the woman has been treated at a provincial hospital. Quang Ninh province bordering China has one of the highest number of HIV carriers in Viet Nam, most of them drug addicts and prostitutes. The fate of the patient experiencing HIV and AI virus co-infection may give an initial indication of any effect of HIV status on susceptibility to avian influenza virus infection. The HIV patient appears to be resisting AI virus infection better than some of those not known to be HIV carriers, and hopefully the outcome will show that an HIV/AIDS status does not predispose individuals to greatly enhanced risk. (Promed 4/14/05)

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North Korea: UN expert says N. Korean bird flu different from version in Southeast Asian
The strain of bird flu that has struck poultry in North Korea is different from the one that has killed people in Southeast Asia, a UN expert said 5 Apr 2005. North Korea has killed some 219 000 birds on 3 farms within a 5km radius of Pyongyang, said Hans Wagner, a veterinarian for the UN Food and Agriculture Organization. FAO tests confirmed those done by the North that the birds were infected with the H7 strain -- not the H5 strain. Authorities in North Korea, one of the world's poorest and most secretive countries, were "very co-operative" and agreed to allow further tests on bird samples at labs in China, Britain and Australia, Wagner said. There have been no reports of human infections of any strain of bird flu in North Korea. Officials will try to trace the source of the infection to try and prevent future outbreaks.

Poultry production is one of the few growing sectors in North Korea, which has relied on foreign aid to feed its people since it disclosed in the mid-1990s that its state farm system had collapsed. The number of the country's poultry was estimated at 25.5 million in 2004, about 2 times the level of 1997. According to a new definition of avian influenza in OIE's Terrestrial Animal Health Code, "Notifiable avian influenza" is an infection of poultry caused by any influenza A virus of the H5 or H7 subtypes or by any AI virus with an intravenous pathogenicity index (IVPI) greater than 1.2. (Promed 4/5/05)

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North Korea: Requests help for Avian influenza from FAO/OIE
The Democratic People's Republic of Korea has formally appealed to the international community for assistance in its fight against Avian Influenza, according to the World Organisation for Animal Health (OIE) and the UN Food and Agriculture Organisation (FAO). North Korea's official appeal was made public at an international conference on bird flu, jointly organised by OIE/FAO, in collaboration with WHO. Around 300 key veterinary experts and scientists met to discuss the current scientific information on bird flu and to address different aspects of disease surveillance and control strategies.

North Korea has asked FAO and OIE to provide diagnostic tools and technical assistance for disease control strategies, including vaccination. OIE and FAO welcomed North Korea's request as a sign of improved transparency and international cooperation. Both organisations said that they are ready to extend their technical support to ensure an effective control of the disease in the country. FAO experts have already been fielded to Pyonyang and are currently supporting the government in obtaining information on the extent of the outbreaks and designing control strategies. OIE has been asked to assist in the training of veterinary experts.

The FAO/OIE conference appealed to donor countries to provide more funds for the fight against avian influenza for which around USD 100 million would be urgently required. So far, only Germany, Japan and The Netherlands have expressed their willingness to financially support affected Asian countries. Many of the countries affected or threatened by AI are under-resourced and lack the capacity of veterinary services for an effective and early detection and response to the epidemic in poultry.

Improving the efficiency of veterinary services in affected countries is essential for controlling the disease at its source in poultry and free-farmed ducks. Strategies are needed for financing sustainable, concrete actions at local level. This is likely to include support for restocking or compensation for losses and should also encompass education on safe poultry keeping and development of appropriate infrastructures. Further scientific research is required to obtain more information on the potential virus transmission from animals to humans. The conference also urged laboratory networks coordinated by WHO, OIE/FAO to conduct research on H5N1 bird flu virus and other avian influenza viruses that could pose a potential threat to humans. Veterinary and Public Health Services should better work together to improve national, regional and global health security. Public Health Services should support the agriculture sector and veterinary services in order to control and eliminate the disease at its origin.

OIE and FAO announced the launch of the New Worldwide Avian Influenza Network (OFFLU) which will improve the collaboration between reference laboratories specialised on AI in animals, coordinated by OIE and FAO and laboratory networks focusing on human influenza coordinated by WHO. The network will speed up the immediate exchange of scientific data on bird flu and animal virus strains to produce efficacious vaccines for humans that respond to specific virus characteristics. (For more information on the OIE/FAO/WHO conference, see the FAO article at: http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/special_avian.html) (Promed 4/8/05)

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North Korea: Requests Seoul's Help to Fight Bird Flu
North Korea on 8 Apr 2005 thanked South Korea for its offer to help contain an outbreak of bird flu at 3 chicken farms and requested that Seoul provide equipment and medical supplies, the Unification Ministry said. South Korea's National Veterinary Research and Quarantine Service received a telephone call from its Northern counterpart, responding 10 days after Seoul first offered assistance. South Korea offered to provide assistance to the North through a telephone communication at the border village of Panmunjom 29 Mar 2005. The Unification Ministry also said the North had conducted 2 genetic tests to confirm the outbreak was of the H7 strain. Pyongyang officials believed the virus was spread by migratory birds, it said. The FAO earlier confirmed that no new cases of bird flu have been reported in North Korea since authorities culled about 210 000 chickens late Mar 2005. No human infection has been detected. However, experts have raised concerns that H7-infected birds could come in contact with H5N1 and create a lethal, fast-spreading hybrid. (Promed 4/9/05)

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China: Explanation on Using Vaccines for the Prevention of Avian Influenza in China
From: GAIN Report CH5028, USDA Foreign Agricultural Service (FAS), 28 Mar 2005. http://www.fas.usda.gov/gainfiles/200503/146119248.doc. The following GAIN (Global Agriculture Information Network) report is an unofficial translation of an update on China's efforts to vaccinate poultry against avian influenza. The report relates to 3 avian influenza vaccines approved for use by the Chinese Ministry of Agriculture (MOA) between Dec 2003 and Jan 2005.

Based on the "National Emergency Plan Against High Pathogenic Avian Influenza" (HPAI), China has inoculated poultry flocks in areas susceptible to avian influenza infection. China has also inoculated poultry flocks on breeding farms, large-sized egg layer farms and in areas with a high concentration of water bodies. Poultry in certain areas designated "no enforced inoculation areas" or "no disease infected areas" have not been inoculated. Other areas apply voluntary inoculation. From Feb 2004 to Jan 2005, China has inoculated a total of 2.68 billion birds. The objective of China's poultry vaccine is to inactivate H5N1. During 2004, this vaccine played an important role in HPAI elimination and prevention in China. The vaccine is only manufactured at the plants designated by the Chinese Government.

The National Reference Laboratory has also developed 2 new vaccines. One is a recombinant AI H5N1 virus inactivated vaccine, and the other is a H5N1 fowl pox live virus vaccine. They are highly efficient, safe and can be produced cost-effectively. The recombinant H5N1 virus inactivated vaccine even works better against the HPAI because its protective period for chickens is longer, and it is especially effective for waterfowl immunity. The vaccine can efficiently stop the spread of the HPAI virus. Now, it is widely used for waterfowl inoculation in water concentrated areas in South China.

In order to strengthen disease control and guarantee inoculation quality, the MOA has carried out regular inoculation supervision and evaluation through sampling serum and pathogen tests among inoculated poultry flocks. Up to now, we have not isolated any H5N1 virus from our inoculated poultry flocks. At the same time, some provinces in South China have adopted a measure of placing inoculated poultry in highly exposed areas to watch the result of infection.

A. AI inactivated vaccine (H5 sub-type, N-28 strain)
1) Seed virus: A/Turkey/England/N-28/73, low virulent strain imported from Weybridge Laboratory Lab in Britain.

2) Result: The antibody level reached the highest rate, 8 log2, during the 5th week after vaccination. This rate was maintained for 4 weeks. The antibody protective level can be sustained into the 23rd week after vaccination.

3) Feature: MOA approved this vaccine as a new bio-product for animal inoculation in Dec 2003. This vaccine was widely used in China during the outbreaks of HPAI at the beginning of 2004.

B. Recombinant AI virus inactivated vaccine (H5N1 sub-type, Re-1 strain)
1) Seed virus: Artificially modified conventional seed virus A/Goose/Guandong/1996 (H5N1), which is representative for the antigen in China, to make H5N1 virus inactive through recombination with human flu virus.

2) Result: The antibody reached highest level of 9 log2 during the 3rd week after vaccination. This rate was maintained for 4 weeks. The antibody protective level can be sustained into the 25th week after vaccination.

3) Feature: MOA approved this vaccine as a new bio-product for animal inoculation in Jan 2005. It works efficiently for avian influenza, it helps poultry organs generate high levels of antibodies and the protective period lasts longer. The laboratory experiments proved that waterfowl inoculated with this vaccine are free of AI infection or infectivity. Many countries in the world now use this method to try to develop vaccines, but only China has succeeded and put the vaccine into commercial production.

C. Recombinant fowl pox virus live vaccine for AI (H5 sub-type)
1) Seed virus: Use A/Goose/Guangdong/1996 (H5N1) as part of gene donor to make a recombinant fowl poxvirus for a live vaccine.

2) Result: The antibody reached the highest level of 7 log2 during the 2nd week after vaccination. The antibody protective level can be sustained into the 26th week after vaccination.

3) Feature: MOA approved this vaccine as a new bio-product for animal inoculation in Jan 2005. It helps create antibodies against the antigen of specific proteins. It is good to differentiate immunity and field infection. Mexico also has this kind of vaccine and widely uses it.

During 2005, the Chinese Government will invest over RMB 5 billion (approximately USD 600 million) in animal disease control. (Promed 4/2/05)

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Cambodia: Avian influenza WHO situation update
As of 12 Apr 2005, The Ministry of Health in Cambodia confirmed that an 8-year-old girl from Kampot province who died 7 Apr 2005, was the country's 3rd case of avian influenza. The girl became ill with a fever 29 Mar 2005. Her condition deteriorated rapidly on 7 Apr 2005, when she was taken to a district referral hospital and then transferred to Kuntha Bopha Hospital, where she died. Samples from the girl tested positive for avian influenza H5N1 virus at the Pasteur Institute, Phnom Penh. A field investigation was conducted immediately, with team members from the Ministry of Health, Ministry of Agriculture, WHO, Pasteur Institute and FAO. Poultry deaths occurred in this village in February, but no poultry deaths occurred in the 2 weeks prior to the girl's onset of symptoms.

Human-to-human transmission as a source of the girl's infection appears unlikely, as none of her known contacts were sick with similar symptoms before she became ill. Investigations as to the source of the girl's infection are continuing. Samples were collected from 4 close contacts who cared for her at the village and 9 medical contacts from Kampot and Phnom Penh. All have tested negative for the H5N1 virus. The public education campaign in Banteay Meas and neighbouring districts is continuing. The recent funding from international donors will be crucial in helping Cambodia control this disease.

"We know she was in contact with chickens when they were dying in Feb 2005, but the exposure period is too long," WHO official Megge Miller said. "We're looking at the potential role of ducks as asymptomatic carriers," she said, noting that it was common for ducks not to show signs of the disease but still carry and spread the virus. Cambodia's first 2 victims, a woman aged 25 who died in January 2005 after traveling to Viet Nam for treatment in January 2005, and a 28-year-old man who died Mar 2005, were also from Kampot province, which borders Viet Nam. (Promed 4/12/05, 4/11/05)

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Indonesia: Avian Influenza Virus Identified in Pigs
Ca Nidom, a molecular biology researcher from the Centre for Tropical Disease Control, Airlangga University, Surabaya, East Java, has reportedly identified avian influenza virus in throat swabs and sera of pigs by RT-PCR. Inactivated RNA isolates have been sent to Tokyo University, where 8 fragments (HA, NA, PA, PB1, PB2, M, NP, NS) were sequenced. Results showed that the virus was (structurally?) similar to the avian influenza virus from poultry, and is characterised by high pathogenicity (based on the study regarding the cleavage site). The serotype of the virus does not appear to have been established, so it cannot be assumed at this stage that the virus is the H5N1 East Asian epidemic strain. (Promed 4/12/05)

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New Zealand: Disease strikes research scientist (Wellington)
A British scientist contracted meningococcal disease while studying the deadly illness in Porirua. The woman, who was working in a lab run by crown research institute ESR, is in a critical condition in Wellington Hospital, with blood infection caused by the disease. It is understood that her legs and an arm will be amputated but her condition is too unstable to allow surgery. The woman is one of 5 unrelated meningococcal disease cases reported in the Wellington region in the past 2 weeks.

ESR chief executive John Hay said the source of infection was unknown. Overseas expert Andrew Lawrence reviewed the lab's practices and reported that there were no recorded accidents. He had no reason to assume the disease was acquired in the lab. Mr Hay said the woman had worked with many strains of meningococcal disease before coming to work at the Kenepuru Science Centre. ESR has been researching a New Zealand strain of meningococcal bacterium for about 15 years. Medical officer of Health Annette Nesdale said that, the latest cases showed the meningococcal disease epidemic was far from over and demonstrated the importance of immunization. All 5 patients had been admitted to hospital; 3 had already been discharged and only the scientist remained in intensive care. Wellington Hospital infectious diseases specialist Tim Blackmore said the number of patients admitted with meningococcal disease in the past few weeks was unusual, but the disease was generally more common in winter. Health boards in the Wellington region are preparing to immunize more than 100 000 babies, children and teenagers starting May 2005. It is not stated what serotypes were involved; nor is it stated whether the researcher had previously received meningococcal vaccination. (Promed 4/7/05)

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Russia: 5 humans develop trichinellosis in Buryatiya after consuming dog meat
5 people in the village Novaya Bryan, Buryatiya Republic have developed trichinellosis after they ate dog meat. One of them is in severe condition. It was established that of the 13 young people who ate the dog meat, 5 are confirmed to have trichinellosis, and the rest have been hospitalized. It seems unlikely that people would deliberately eat dog meat, but the meat could illegally have been used. Meat sold as if from other species has been reported previously, and the previous outbreak of trichinella in Siberia from meat from a badger and bear suggest that meat from unusual sources may find its way into the diet in Russia. (Promed 4/7/05)

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Quarantine and isolation were last used during the SARS outbreak in 2003. The last large-scale quarantine was during the Spanish flu pandemic of 1918-19, though there have been lesser quarantines -- for instance, travelers coming off airliners or cruise ships who have been exposed to curable diseases. Jennifer Morcone, a spokeswoman for the health centers, said Mr. Bush's executive order was intended to prepare for all options. The Public Health Service, Ms. Morcone said, would typically recommend voluntary home quarantine when possible. In general, the government defers to state and local authorities in their use of quarantine powers and would work with them in case of an outbreak, she said. (Promed 4/2/05)

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Mexico: Report of low-pathogenic avian influenza
Mexico's Agriculture Ministry has reported an outbreak of low-pathogenic avian influenza in northern Mexico, in the state of Durango. Early last week, bird flu fears prompted the slaughter of approximately 2 million chickens at a Tyson Foods processing plant. It is not known how the disease entered the country, but Mexico recently resumed poultry imports from Texas, which was affected by low-path AI in 2004. Since the bird flu was not a high-pathogen strain, the outbreak was not reported to the WHO. The type of low pathogenic avian influenza is unknown. (Promed 4/7/05)

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USA/Canada: Strain of Clostridium difficile produces high levels of toxins A and B
The emergence of a highly toxigenic strain of Clostridium difficile may be responsible for an outbreak of disease at the Centre Hospitalier Universitaire de Sherbrooke (CHUS) in Quebec, Canada, according to the results of a study to be presented at the 15th annual scientific meeting of the Society for Healthcare Epidemiology of America (SHEA) in Los Angeles, CA, USA.

According to an SHEA news release, the toxic strain is identical to that which caused outbreaks in 7 hospitals across 6 US states, 2001 to 2004. Data presented in 2004 at the Infectious Diseases Society of America meeting suggest that the bacterium is resistant to fluoroquinolone therapy. The study was initiated to identify the emergent strain related to the quadrupled incidence of C. difficile-associated diarrhea and almost doubled case-fatality ratio observed at CHUS during 1991 to 2003, as reported in an earlier study by Jacques Pepin, MD. "The perception of a number of physicians is that the strain they are dealing with is more virulent than usual," Michel Warny, MD, PhD, lead investigator and director of bacterial process development for Acambis Inc, told Medscape. "This is illustrated by the substantial increase in mortality per case of C. difficile infection since the year 2000."

In the study, a single identical strain (toxinotype III) was identified in 82 percent of isolates collected from patients involved in the CHUS outbreak. Dr. Warny noted, "This finding was significant because in general the toxinotype III strain is found in only 2 percent of isolates." Further, the toxinotype III strain was found to produce 16 times more toxin A and 20 times more toxin B in vitro compared with 13 variations of the toxinotype 0 strain commonly found in 80 percent of isolates. "The main pathogenic factor of C. difficile is the production of these 2 toxins," said Dr. Warny, suggesting that the ability of the emerging strain to produce up to 20 times more toxin than more common strains may explain reports of its virulence. (Promed 4/12/05)

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USA (Michigan): Drug-resistant staph infection spreading
A man admitted 8 Apr 2005 to the Kent County Jail complained about boils on his skin, and officials suspect he has a staph infection. The sometimes deadly infection is known as MRSA, or methicillin-resistant Staphylococcus aureus, and is becoming more widespread -- especially in places where people share close quarters. In Kent County, medical staff since Feb 2005 have treated several MRSA cases at the jail, said Sgt. Larry Quakkelaar. The inmate admitted Friday is in isolation. Kent County jail inmates are given pointers about what the infection looks like and how it can be avoided. “We're telling staff to wear gloves to pat down inmates, and we're telling inmates, don't share your washcloth, your towel, your toothbrush or your shaver…And wash your hands frequently," Quakkelaar said.

MRSA is a skin and soft tissue infection. It is also found in some pneumonias, said Dr. Lilly Immergluck, an infectious disease specialist at DeVos Children's Hospital. It has also turned up on athletic teams, among Marine recruits, and in hospitals and nursing homes. The MRSA infection has 2 epidemiological strains: 1 picked up in hospitals and the other in the community. In hospitals, it is most likely to strike those already in a weakened state. It is suspected of causing 2 million infections and 88 000 deaths worldwide each year. The community-acquired infection is appearing in healthy people as well as those with weakened immune systems, Immergluck said. Doctors and hospitals aren't required to report single cases of MRSA, so it's impossible to get accurate figures about prevalence, said T.J. Bucholz, a spokesman for the Michigan Department of Community Health. However, health officials do report outbreaks or clusters of cases. "We know anecdotally, though, that we are hearing of more cases now," Bucholz said. Community-associated (CA) MRSA has become a common and serious problem.

***In the 7 Apr 2005 issue of the New England Journal of Medicine, there are 2 full-length publications, 2 letters, and an editorial regarding CA MRSA. (Promed 4/12/05)

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USA: Florida outbreak of E. coli is traced to 6 petting-zoo animals
6 farm animals at a Florida petting zoo have been identified as the source of the potentially deadly strain of E. coli bacteria that caused more than 26 people, most of them children, to be hospitalized, state health officials said 8 Apr 2005. As a result, all 37 animals at the zoo have been quarantined. The outbreak dates from late Feb - early Mar 2005, when the zoo, Agventure Farm Shows, provided petting animals for fairs in Orlando, in Tampa and in Plant City. Of the more than 24 people admitted to hospitals with the illness that followed, 8 remain hospitalized, and the condition of one is critical. In addition, the cases of 41 people who suffered symptoms linked with E. coli O157:H7 have been identified as "suspect." That E. coli strain can cause hemolytic uremic syndrome, a disease in which the kidneys shut down. The syndrome is most dangerous to youngsters and the elderly, and many of the children hospitalized in this outbreak had to be put on dialysis machines because their kidneys had failed.

Agventure was the only zoo to provide animals to the 3 fairs that have been identified as sources of human contact with E. coli. Dr. John O. Agwunobi, Florida's secretary of health, said 8 Apr 2005 that the 6 animals at issue were the only ones identified -- through DNA testing on them and patients -- as carrying the bacteria. State officials said the infected animals -- 2 sheep, 2 calves and 2 goats -- would be permanently barred from contact with the public and from slaughter for human consumption. The problem is that even healthy, well-kept animals can harbor intestinal diseases and parasites harmful to humans. Transmission can occur when animals step or sit in their own feces and then are petted or fed by children, who then put their hands in their mouths. Simple hand-washing is key to preventing transmission of these bacteria and parasites. (Promed 4/8/05, 4/4/05)

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USA: Public Health officials report on tularemia outbreak at Boston University
The Boston Public Health Commission (BPHC) released its report on the tularemia outbreak at Boston University that occurred in 2004. The 15 page report, which is authored by Dr. Anita Barry, the BPHC's director of Communicable Disease, draws the following conclusions:

1. At this time, the source of Type A F. tularensis in the BU laboratory remains unknown. The federal investigation into the incident is pending.

2. The extensive investigation to date has found no evidence to indicate that either the contamination of the LVS stock or the infections of the BU researchers were intentional.

3. The tularemia outbreak at BU was limited to 3 BU employees and never posed a risk to the public at large.

4. The failure to identify work-related illness in laboratory staff is a major concern for health officials.

5. The failure to immediately report suspicious work-related illness to local and state health departments is a major concern.

6. Appropriate infection control practices in laboratories must be clearly documented for all workers and enforced.

7. The BU Institutional Biosafety Committee was not able to ensure compliance with appropriate laboratory protocols and procedures.

The full report can be found at: http://www.bphc.org/reports/pdfs/report_202.pdf (Promed 4/13/05)

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Canada: Ontario issues warning against unpasteurized milk
Dr. Sheela Basrur, Ontario's Chief Medical Officer of Health, warned the public11 Apr 2005 not to consume unpasteurized milk. This warning is based on an investigation that showed that 3 cases of E. coli O157 in Simcoe County might have resulted from the consumption of unpasteurized milk. All 3 individuals have been released from the hospital and are recovering at home. The sale or distribution of unpasteurized milk is prohibited under the Health Protection and Promotion Act. The Simcoe Muskoka Health Unit is leading the investigation. Dr. Basrur said, "Anyone with nausea, fever, vomiting or diarrhea who consumed unpasteurized milk should contact their doctor immediately."

E. coli O157:H7 is just one of a number of infections that can be transmitted to humans from unpasteurized milk or dairy products. These include Salmonella sp and Campylobacter sp, both of which may be multi-drug resistant, as well as staphylococcal food poisoning, Q fever, listeriosis, brucellosis as well as bovine tuberculosis. Additionally, Brainerd diarrhea, a chronic diarrheal process of unknown etiology is also associated with raw milk ingestion. Symptoms of E. coli O157 include severe stomach cramps and diarrhea (sometimes bloody). Young children and seniors are also at higher risk of developing serious complications, which can be fatal. Dr. Basrur is also asking the public to report sales of unpasteurized milk to the Ministry of Agriculture and Food's complaint line: 1-888-466-2372 ext. 64391. The Ministry of Health and Long-Term Care continues to monitor the situation. (Promed 4/11/05)

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Canada. Overall influenza activity continued to decline, with widespread activity reported in 2 provinces. Of the influenza viruses detected during week 12, 42% were influenza A and 58% were B viruses.

Hong Kong. The number of influenza viruses isolated increased significantly in weeks 11–12, although overall influenza activity remained medium–low. Influenza A(H3N2) and B viruses co-circulated.

Japan. Influenza activity continued to decline and was reported as sporadic in week 12.

Russia. A decrease in influenza activity was observed in week 12, although widespread activity remained.

USA. Influenza activity continued to decline in weeks 11–12. The overall ILI consultation rate was still above the national baseline, although it has declined during the past 5 weeks. The proportion of deaths attributable to pneumonia and influenza remained above the epidemic threshold. During weeks 10–11, 6 additional influenza-associated pediatric deaths were reported. Of the influenza viruses detected in week 12, 37% were influenza A viruses and 63% were B viruses.

Other reports. During weeks 11–12, Brazil, Chile, Malaysia and Mexico reported no influenza activity. (WHO 4/7/05 http://www.who.int/csr/disease/influenza/update/en/print.html)

USA, from CDC Weekly Report: Influenza Summary Update, Week ending April 9, 2005-Week 14
Influenza activity in the US peaked in early February and continued to decline during week 14 (April 3-9, 2005). 157 (8.3%) specimens tested by U.S. WHO and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories were positive for influenza viruses. The proportion of patient visits to sentinel providers for influenza-like illness (ILI) was below the national baseline. The proportion of deaths attributed to pneumonia and influenza has been above the epidemic threshold during the last 8 weeks. There have been 28 influenza-associated pediatric deaths reported to CDC this season. (CDC 4/15/05 http://www.cdc.gov/flu/weekly/)

An MMWR summary of influenza activity in the US during Oct 3, 2004--Mar 26, 2005 is available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5413a2.htm.

Addendum to the recommended composition of influenza virus vaccines for 2005-2006 season
WHO published interim recommendations on the composition of influenza vaccines for use in the 2005-2006 influenza season on 10 Feb 2005. The decision on A(H3N2) candidate vaccine viruses was postponed pending the identification of a suitable high growth reassortant. Based on the results of antigenic and genetic analyses and growth in hens' eggs, obtained by WHO Collaborating Centers for Reference and Research on Influenza and Reference Laboratories, a high growth reassortant virus derived from A/New York/55/2004 (A/California/7/2004-like) virus and A/PR/8/34, is suitable as a candidate A(H3N2) vaccine virus. Accordingly, it is recommended that the vaccines for use in the 2005-2006 influenza season (northern hemisphere winter) contain a trivalent vaccine containing: 1) an A/New Caledonia/20/99(H1N1)-like virus 2) an A/California/7/2004(H3N2)-like virusa 3) a B/Shanghai/361/2002-like virus b. (Promed 4/13/05)

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Dengue/DHF
Mexico (Sonora)
12 days after the occurrence of symptoms resembling a common cold, a 59-year-old man from Cobachi community, La Colorada, Mexico, died after developing hemorrhagic dengue fever. The patient is the fourth individual from Sonora State infected with the dengue virus, and he was the first man to die this season from the disease. The patient felt ill 9 Mar 2005; 4 days later he was admitted at the State General Hospital, where he had 2 cardio-respiratory arrests. The diagnosis was confirmed by the State Health Laboratory. Mexico Health Secretary, Dr. Raymundo Lopez-Vucovich, decreed a public alert and asked Sonorans to keep their yards clean to eliminate mosquito breeding habitats. (Promed 4/8/05)

Hong Kong
The Centre for Health Protection has confirmed a Dengue fever case involving a 44-year-old woman, bringing 2005's total to 3, all imported. The Tsing Yi woman traveled to Indonesia 14-23 Mar 2005 and came down with fever and muscle pain on 20 Mar 2005. She was discharged from Princess Margaret Hospital 31 Mar 2005 and has recovered. Her husband, who had traveled with her, developed fever and headache 28 Mar 2005 and is at Princess Margaret Hospital. People should stay alert to the threat of Dengue fever and take measures against mosquito breeding and bites. Travelers should wear long-sleeved tops and trousers and use insect repellent. They should also seek medical advice as soon as possible if they feel unwell after returning from their trip. (Promed 4/8/05)

East Timor
An epidemic of dengue fever has killed more than 40 people in East Timor since the beginning of 2005. Portuguese newspapers say the Government has called for a major clean-up campaign to eliminate the mosquitoes that spread the viral disease. East Timor is one of several areas currently affected by the disease, which is endemic in the Asia-Pacific region. The 4 strains of the dengue virus cause symptoms ranging from a non-specific viral syndrome to severe and fatal hemorrhagic disease. (Promed 4/8/05)

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Outbreaks of Salmonella Infections Associated with Eating Roma Tomatoes—US and Canada, 2004
“Three outbreaks of Salmonella infections associated with eating Roma tomatoes were detected in the United States and Canada in the summer of 2004. In one multistate U.S. outbreak during June 25--July 18, multiple Salmonella serotypes were isolated, and cases were associated with exposure to Roma tomatoes from multiple locations of a chain delicatessen. Each of the other two outbreaks was characterized by a single Salmonella serotype: Braenderup in one multistate outbreak and Javiana in an outbreak in Canada. In the three outbreaks, 561 outbreak-related illnesses from 18 states and one province in Canada were identified. This report describes the subsequent investigations by public health and food safety agencies. Although a single tomato-packing house in Florida was common to all three outbreaks, other growers or packers also might have supplied contaminated Roma tomatoes that resulted in some of the illnesses. Environmental investigations are continuing. Because current knowledge of mechanisms of tomato contamination and methods of eradication of Salmonella in fruit is inadequate to ensure produce safety, further research should be a priority for the agricultural industry, food safety agencies, and the public health community…” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5413a1.htm (MMWR April 8, 2005 / 54(13);325-328)

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Health Concerns Associated with Disaster Victim Identification After a Tsunami--Thailand, December 26, 2004--March 31, 2005
“The number of persons confirmed dead from the Indian Ocean tsunami that struck on December 26, 2004, had exceeded 174,000 as of March 31, 2005; the majority of decedents were buried or cremated without being identified. In contrast, in Thailand, disaster victim identification (DVI) continues, with approximately 1,800 persons identified among the 5,395 persons confirmed dead; of the dead, approximately 50% were not citizens of Thailand. This large-scale, multinational effort faced immediate challenges, including establishment of four temporary morgues, implementation of safeguards against environmental and occupational health hazards, and coordination of forensic procedures and safety protocols among Thai and international forensic teams. Public health and other agencies performing large-scale DVI in temporary morgues might consider implementing the recommendations and procedures described in this report…” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5414a1.htm (MMWR April 15, 2005 / 54(14);349-352)

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Preliminary FoodNet Data on the Incidence of Infection with Pathogens Transmitted Commonly Through Food--10 Sites, US, 2004
“Foodborne illnesses are a substantial health burden in the United States. The Foodborne Diseases Active Surveillance Network (FoodNet) of CDC's Emerging Infections Program collects data from 10 U.S. sites on diseases caused by enteric pathogens transmitted commonly through food. FoodNet quantifies and monitors the incidence of these infections by conducting active, population-based surveillance for laboratory-diagnosed illness. This report describes preliminary surveillance data for 2004 and compares them with baseline data from the period 1996--1998. The 2004 data indicate declines in the incidence of infections caused by Campylobacter, Cryptosporidium, Shiga toxin--producing Escherichia coli (STEC) O157, Listeria, Salmonella, and Yersinia. Declines in Campylobacter and Listeria incidence are approaching national health objectives; for the first time, the incidence of STEC O157 infections in FoodNet is below the 2010 target. However, further efforts are needed to sustain these declines and to improve prevention of foodborne infections; efforts should be enhanced to reduce pathogens in food animal reservoirs and to prevent contamination of produce…” http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5414a2.htm (MMWR April 15, 2005 / 54(14);352-356)

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CDC International Course in Applied Epidemiology
CDC and Emory University's Rollins School of Public Health will cosponsor a course, "International Course in Applied Epidemiology", Sep 26--Oct 21, 2005, in Atlanta, Georgia. This course is directed at public health professionals from countries other than the US and will include presentations and discussions of epidemiologic principles, basic statistical analysis, public health surveillance, field investigations, surveys and sampling, and discussions of the epidemiologic aspects of current major public health problems in global health. Included are small group discussions of epidemiologic case exercises based on field investigations. Participants are encouraged to give a short presentation reviewing epidemiologic data from their own country.

Computer training using Epi Info, a software program developed at CDC and the WHO for epidemiologists, is included. Prerequisites include familiarity with the vocabulary and principles of basic epidemiology or completion of CDC's "Principles of Epidemiology" home-study course or equivalent. Early registration deadline is Jun 1; late registration deadline is Sep 1. Additional information is available from Emory University's Rollins School of Public Health, International Health Dept. (Attn: Pia), 1518 Clifton Road, N.E., Room 746, Atlanta, GA 30322; fax, 404-727-4590; at http://www.sph.emory.edu/epicourses; or by email, pvaleri@ sph.emory.edu. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5413a6.htm (MMWR April 8, 2005 / 54(13);336)

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50th Anniversary of the First Effective Polio Vaccine--April 12, 2005
April 12, 2005, marks the 50th anniversary of the announcement that the polio vaccine, developed by Jonas Salk and his team of scientists at the University of Pittsburgh, worked. "Safe, effective, and potent" were the words used to announce to the world that an effective vaccine had been found against a disease that once paralyzed 13,000--20,000 persons each year in the United States. In 1979, fewer than 25 years after introduction of the vaccine, the last indigenously acquired case of polio caused by wild poliovirus was detected in the US; 15 years later, in 1994, the Western Hemisphere was certified polio-free.

Through support by the National Foundation for Infantile Paralysis (the March of Dimes), Thomas Francis Jr. of the University of Michigan led the pioneering field studies of inactivated polio vaccine that led to the April 12, 1955, announcement. Approximately 1.8 million children from 217 areas of the United States, Canada, and Finland participated in the vaccine field studies. Thousands of health-care workers and lay persons volunteered to assist with the field studies, the largest ever in U.S. history. The National Foundation for Infantile Paralysis also supported the development work of Albert Sabin, whose oral polio vaccine (OPV) was licensed in 1961. The Global Polio Eradication Initiative, spearheaded by the WHO, Rotary International, UNICEF, and CDC, was begun in 1988. That year, an estimated 350,000 children were stricken with polio worldwide; in 2004, polio cases had decreased to approximately 1,200 cases globally. Although the Americas are polio-free, the disease still exists in some countries in Asia and Africa. Using the Sabin OPV, the Initiative continues to conduct immunization campaigns in those countries that have not been declared polio-free.

Information about polio disease, vaccine, and eradication efforts is available at http://www.cdc.gov/nip.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5413a5.htm (MMWR April 8, 2005 / 54(13);335-336)

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National Infant Immunization Week--April 24--30, 2005
National Infant Immunization Week (NIIW) is April 24--30, 2005. The theme this year is "Vaccination: an Act of Love. Love Them. Protect Them. Immunize Them." This annual event emphasizes the importance of timely infant and childhood vaccination, one of the most effective ways to protect infants and children from potentially serious diseases. Because of increased emphasis on vaccination, the majority of vaccine-preventable diseases have decreased in incidence by approximately 99% from peak prevaccine levels in the US. In 2004, a total of 37 cases of measles, no cases of diphtheria, and no cases of wild poliovirus were reported in the US. Approximately 11,000 infants are born each day in the US; according to the recommended childhood immunization schedule, they require approximately 23 doses of vaccine before age 2 years to protect them from 12 vaccine-preventable diseases. Although vaccination coverage levels are high for children of preschool age, an estimated 27.5% of children aged 19--35 months were missing 1 or more recommended vaccine doses in 2003.

During NIIW, states and hundreds of communities throughout the US will sponsor activities highlighting the need to achieve and maintain high childhood vaccination coverage rates. Special kick-off events, including provider education activities, media events, and immunization clinics are planned along the US--Mexico border in collaboration with state and local health departments, the US--Mexico Border Health Commission, and PAHO. In addition, CDC and its partners will introduce a new public education campaign. NIIW is being held in conjunction with Vaccination Week in the Americas, scheduled for April 23--30. That event, sponsored by PAHO, promotes childhood immunization and access to health services concurrently in all countries in the Western Hemisphere. Additional information about NIIW and childhood vaccination is available from CDC's National Immunization Program at http://www.cdc.gov/nip. Information on Vaccination Week in the Americas is available at http://www.paho.org/english/dd/pin/pr050211.htm.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5414a5.htm (MMWR April 15, 2005 / 54(14);361-362)

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Web Portal to "One World, One Health: Building Interdisciplinary Bridges to Health in a Globalized World" Symposium
Robert A. Cook, V.M.D., M.P.A., Chief Veterinarian & Vice President, Wildlife Conservation Society:
A complete video library of this cutting-edge interdisciplinary symposium is now available online, free of charge. Speaker slide presentations are also viewable: http://www.oneworldonehealth.org. Health experts from around the world met 29 Sep 2004 for a symposium focused on the current and potential movements of diseases among human, domestic animal, and wildlife populations organized by the NY-based Wildlife Conservation Society and hosted by Rockefeller University. Using case studies on Ebola, avian influenza, and chronic wasting disease as examples, the assembled expert panelists delineated priorities for an international, interdisciplinary approach for combating threats to the health of life on Earth. The product, called the "Manhattan Principles" by the organizers of the "One World, One Health" event, focuses on 12 recommendations for establishing a more holistic approach to preventing epidemic/epizootic disease and for maintaining ecosystem integrity for the benefit of humans, their domesticated animals, and the foundational biodiversity that supports us all. (Promed 4/11/05)

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Sixth International Symposium on the Epidemiology and Control of Foodborne Pathogens in Pork
6-9 Sep 2005, Rohnert Park, California, USA
Submissions are now being accepted for Safepork 2005, the Sixth International Symposium on the Epidemiology and Control of Foodborne Pathogens in Pork. The organizing committee is accepting submission of papers until 1 May 2005. Submissions may be considered for poster or oral presentations. Topics for this meeting include pathogens of foodborne importance, antimicrobial resistance, chemical and physical hazards in pork. Papers are sought on epidemiology, economics, diagnostics, risk analysis, intervention practices, monitoring and control and impact on public health. This year's committee encourages graduate students to submit papers for competition. Complete submission and registration instructions can be found at: http://www.safepork2005.org/ (Promed 4/12/05)

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The Second Annual Biosafety and Biosecurity Training Course
The Annual Biosafety and Biosecurity Training Course will be held 8-15 Jul 2005 in Fort Collins, Colorado. A certificate will be given to all who complete the course.

- 8-10 Jul 2005: animal oriented (one day on large animal ABSL-2 and -3 facilities, containment, etc; one day on small animal ABSL-2 and -3 facilities and containment; 1/2 day on veterinary hospital, clinic, and farm and ranch Biosecurity (infection control)).

- 11-12 Jul 2005: general Biosafety and Biosecurity (BMBL, rDNA Guidelines, Biosafety committees, other administration aspects, risk assessment, Select Agent regulations and administration, HEPA filters and biosafety cabinet certification).

- 12-14 Jul 2005: plant oriented (containment of recombinant plants, infectious disease research with plants, biopharm, regulations, permits, plant disease diagnostic lab network, diseases of crops, and greenhouse design and management).

For more information: <http://www.cvmbs.colostate.edu/microbiology/crwad/relatedmeetings.htm> Contact: Robert Ellis, 970-491-6729, robert.ellis@colostate.edu (Promed 4/13/05)

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